Healthcare Provider Details

I. General information

NPI: 1114496312
Provider Name (Legal Business Name): BRIDGE2DREAM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2018
Last Update Date: 11/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6645 DELMONICO DR STE 103
COLORADO SPRINGS CO
80919-1892
US

IV. Provider business mailing address

PO BOX 31093
COLORADO SPRINGS CO
80931-1093
US

V. Phone/Fax

Practice location:
  • Phone: 719-428-6018
  • Fax:
Mailing address:
  • Phone: 719-428-6018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: DAVID DOUGLAS FREEMAN
Title or Position: OWNER
Credential: MA, LPC
Phone: 719-428-6018